note-01
Progress note with provenance
A session note where every passage records where it came from — typed, dictated, template, copied forward, or drafted by the copilot — and the signature refuses until the note has actually been read.
Progress note · 12 Aug 2026
R. Okonkwo · Individual therapy, 50 min · CPT 90834
Session began with a review of the between-session practice. Patient reported that the thought record was completed on four of seven days, and described the fourth entry as the one that shifted something. Affect was brighter than at intake and congruent.
Sleep remains disrupted, averaging four to five hours, with early waking. This was contradicted in session: patient now reports six hours and one early waking in the last week.
PHQ-9 administered at the start of session: 16, unchanged from session 6. Score has not moved in three administrations despite reported behavioural gains.
Plan: continue weekly. Given the flat PHQ-9 against reported improvement, will review the measure with the patient next session to check for item-level masking, and consult in supervision on Thursday.
Read 0%
Measure taken this session
Rendered from the instrument, not retyped into prose
A score typed into a note is a number. A score linked to the instrument is a measurement with a date, a scale and a trend.
Raised for supervision
The note is where the clinical question surfaced. This is where it goes next.
What to look at: One paragraph is copied forward from last week and contradicted by the paragraph after it. That is what the read gate is for: a signature attests that you read what you signed, and the meter makes the precondition visible instead of turning it into a refusal at the last click.